Interview with Dr. Robert Anderson (Part Two): Importance of Including Detail on Death Certificates

HOST: We’re joined today by Dr. Robert Anderson, the Chief of Mortality Statistics at CDC’s National Center for Health Statistics.

HOST: What happens in the instance if the certifiers cut corners or fill out the death certificate quickly and maybe leave out certain things…how does that impact the data?

ROBERT ANDERSON:  Well there are really two issues that we see with cause of death certification, two main issues. Sometimes certifiers leave out the underlying cause and sometimes that they will provide an underlying cause but not provide sufficient details.  So for example we see sometimes acute kidney failure as the cause of death.  There would be a lot of other causes of death that would be applicable here but acute kidney failures is I think illustrative.  In most cases this is probably not incorrect – the decedent may very well have died from acute kidney failure but it’s not really enough information. Acute kidney failure is typically caused by something else and we need to know what that underlying cause was.  Was it diabetes?  An infection?  High blood pressure?  Or some specific disease affecting the kidney?  There are bunch of things that can cause acute kidney failure.  We need to know that information. We didn’t know what that underlying cause was because that’s what we want to focus on from the public health standpoint.

HOST:  Is there anything that can be done when this sort of thing turns up? I mean, is there any follow up or once its complete basically that’s what we have to deal with?

ROBERT ANDERSON:   Well unfortunately once it’s complete that’s generally what we have to deal with.  In an ideal world, all death certificates get reviewed by an expert and information is correct or added as appropriate.  Unfortunately, resources are such that that’s not a practical solution.  So very often we just have to deal with what’s given to us.  Yeah, we also deal with this issue where the underlying cause may be provided we don’t get sufficient detail and drug overdoses provide a good example of where the lack sufficient detail is a problem.  In these cases, sometimes we’ll simply see just “drug overdose” or “multi drug toxicity” reported on the death certificate.  And again, while this is probably not incorrect, we really need to know which drugs were involved.  If all we get is “drug overdose” we don’t know – was it a heroin overdose? Was it a fentanyl overdose?  And knowing which drugs were involved helps us to better understand the nature of the public health problem that we’re dealing with.

HOST:   Usually, when you have a high profile person dying of an overdose there’s often a long period where they’re waiting for the toxicology report.  Does that restrict certifiers getting details like that for the death certificate?

ROBERT ANDERSON:    It really doesn’t.  In most instances when a death investigation is required it’s going to take more than a few days.  The cause of death can be certified pending investigation.  And so that’s typically the way these are handled – the medical examiner or coroner who deal with the drug overdose deaths, they will file the death certificate with the cause and manner of death pending investigation.  And then, so we will get actually that fact of death with pending cause in a very timely manner.  Then once the death investigation is done, the medical examiner or coroner can go into the system and update the cause of death – that’s actually the way they’re supposed to do it, they go in, they amend the certificate with the new cause of death information and then that information is transmitted to us.  So, while we may get the fact of death in a very timely fashion for drug overdose deaths, we very often don’t get cause of death until maybe three to six months later.

HOST:  So the data that NCHS ultimately publishes – that’s coming from all the death certificates in the country that are recorded.  It’s not just a sample of death certificates like we would get with a survey sample for example, is that right?

ROBERT ANDERSON:   That’s right.  Yeah, we don’t do, we’re not sampling data here.  All deaths are required to be registered and we collect all of these from the states for the national statistics.  Now, that doesn’t mean that when we publish information that we necessarily have all of them in that moment.  We do publish some provisional data that are incomplete.  Our final statistics are based on all deaths registered and sent to us by the states.

HOST:  Before we get to the provisional vs. final topic, can you – I know the number changes each year – but how many death certificates are we talking about roughly each year?

ROBERT ANDERSON:   We’re talking about in the most recent years about 2.8 million – 2.8 million deaths in a year.

HOST:  Right.  And so as the population grows you’re going to see more of a volume to go through.

ROBERT ANDERSON:   Yeah that’s certainly what we’ve seen. I mean not only has the population been growing but the population has been aging somewhat and of course an aging population means more deaths as well because older people are more likely to die.  So yes we have been seeing increases in the total number of deaths over time even though in most instances the death rate has come down.

HOST:  Right.  And the death rate is the number of deaths per a certain number of population is that right?

ROBERT ANDERSON:  That’s correct.  Yeah, usually .for mortality we characterize it as deaths per 100,000.

HOST:  Join us next week for part three of our discussion with doctor Robert Anderson on death certificate data in the United States.

HOST:  Now let’s turn to this week’s releases from NCHS.  A new report out on Wednesday presents body measurement data for Americans, using data from the 2015-2018 National Health and Nutrition Examination Survey.  The data showed that an average man in the United States stands 5 foot 9 inches tall and weighs around 200 pounds while the average woman is 5 foot 3 ½ and weighs about 171 pounds.  This anthropometric reference report includes data on height weight body mass index and other measurements by gender and by age.

Also on Wednesday, the latest monthly provisional data on drug overdose deaths in America was released.  This release covers the one-year period ending in June of 2020, and the impact of the pandemic on drug abuse in the country is reflected in the new numbers.  An estimated 83,335 Americans died from drug overdoses in the 12 month period ending in June of 2020 – a staggering 21.3% increase from the year before.  Increases were observed in all states but four: Idaho, Nevada, New Hampshire, and North Carolina.  Opioid deaths top 60,000 during this period, with fentanyl and other synthetic opioids accounting for two-thirds of those opioid deaths.  Methamphetamine and other psychostimulants accounted for over 20,000 drug overdose deaths, and cocaine deaths topped 19,000 for this period. Keep in mind that many overdose deaths involve a combination of these and other drugs or alcohol.

On Thursday, NCHS released its latest provisional quarterly data on death rates in the United States, through June of 2020. The overall death rate in the U.S. increased in the 12 months ending in June 2020 to nearly 754 deaths per 100,000 – up from 714 per 100,000 the year before.  The increase in the overall death rate reflects the arrival of the pandemic in the U.S., and the release features the first estimated death rate for COVID-19, in Quarter 2 of 2020.  The Quarter 2 death rate for COVID-19 was nearly 109 deaths per 100,000 population.  To put that into context, the Quarter 2 death rate for cancer, which is the 2nd leading cause of death in the U.S., was a little over 139 deaths per 100,000.  This latest release contains several new features, including data by age gender and state.